Schizophrenia and related psychosis.

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  The author of this work is currently employed as a community psychiatric nurse whose remit is to work with those clients with serious and enduring mental illness, the majority of whom have a medical diagnosis of schizophrenia and related psychosis.

Over the past 10 years there's been a growing movement towards diverse treatments for schizophrenia other than the acknowledged role of medication as a treatment modality (Birchwood and Tarrier 1993). Developments in psychological theory have led to a number of innovative psychological treatments drawn from human experimental psychology such as behavioural and social psychology and cognitive science.

 Therapies based on cognitive behavioural theory have been rapidly developing, initially for the so called ‘neurotic disorders’ but in recent years evidence has accumulated to suggest that these cognitive behavioural approaches can be effective for those people suffering from psychosis ( Williams 1995).

The aim of this assignment is to explore the basis of Cognitive Behavioural Therapy and review its’ therapeutic application to schizophrenia.                        Cognitive Behaviour Therapy (CBT) is an evolutionary paradigm that came about a from the merging of the established paradigm of behavioural therapy and contemporary cognitive therapy (Clarke and Fairburn 1997). Behavioural therapy historically focused on anxiety, phobic and obsessional disorders. Treatments were aligned to the learning theories of Pavlov and Skinner, anxieties and phobias were conceptualise to be conditioned fear responses, passively acquired and elicited by conditioned stimulii (Clarke and Fairburn 1997). A  variety of techniques were employed to enable the client to ‘unlearn’ these acquired behaviours. These treatments regimes were concerned with maladaptive habits and behaviours; thought and emotional responses where considered reactive and of no influence to these behaviours. Behaviour was considered to be primarily shaped by environmental factors and therapy was by exposure to a sequence of environmental events.

Cognitive approaches to psychological therapy emphasise the meaning given to mental processes that intervene between environmental events and the reaction to that event. Events that take place are evaluated and classified in various ways, comparisons are made with previous experiences from stored memory. Reaction to events, are a result of this cognitive filtering and are therefore contextual in nature. Cognitive psychology is concerned with thought and perception, memory, learning language, concept formation and problem solving (Brewin 1988). In addition cognitive social psychology emphasises conscious attitudes, expectancies and beliefs.  It is posited that such psychological disorders as anxiety and depression are directly related to people's perception and evaluation of events in their lives rather than the events themselves (Clarke1997). A basic tenet of cognitive behavioural therapy is that an individual's perception of events and experience has a powerful effect upon subsequent emotional behaviour and psychological responses attuned to the autonomic nervous system (Clarke 1997)

The merging of aspects of behavioural psychology and cognitive psychology where welded together by the successful development of treatment for panic disorder and depression, whilst at the same time adopting outcome research by subjecting treatment methods to rigorous empiricism. Cognitive therapy could supply content to behaviour therapy (Clarke 1997)

CBT was developed by Aaron Beck in the early 1960s. It is a short term treatment carried out in the ‘the here and now’. It is structured towards solving current problems and modifies dysfunctional thinking and behaviour (Beck 1995)

Through a process of realistic evaluation and subsequent modification of ingrained thought processes, improvements in mood and behaviour can be achieved. Becks’ model incorporates a system of psychotherapy with a ‘unified theory of personality and psychopathology supported by a substantial empirical evidence’ (Beck 1995 p1). CBT has subsequently been adopted to treat a whole constellation of disorders including more recently psychosis. To enable CBT techniques to be used across a whole range of psychological disorders, treatment must be based upon a cognitive formulation of the disorder and applied within the clients' own belief system. The therapist seeks to produce cognitive change within the clients' systems of thinking and beliefs in order to destabilise dysfunctional emotional and behavioural systems. The theory is based on the concept of an individual's need to process information and subsequently adapt in order to survive. Much of this process lies outside of conscious awareness. The process of information interpretation is in the adaptation of a series of coding systems where selected data is integrated and interpreted and subsequently stored. These organised belief systems or schemas are laid down as the foundations of a belief system, they comprise an emotional, physiological and cognitive memories and experiences. This cognitive, effective and behavioural network produces a synchronised response to external stimuli that is outside of immediate awareness, it therefore provides a mechanism for internal motivation and aims (Beck 1996). Schemas can be classified as sub-structures of the various systems that comprise human personality. Beck (1996) categorises the systems into; cognitive system, affective system, motivational and behavioural system, physiological system and the conscious control system. The cognitive system is responsible for the processing of information and attribution of meaning, memory and memory recall. This is relevant to a person's perceptions and construction of themselves and others, of self worth and social desirability.  Processing of schemas are out of awareness but the contents can be accessed at the conscious level. Memories play a significant part in the system, past memories often mould reaction to present events. Beck (1995) describes experiences as being ‘abstracted and organised’ (P 5) in relation to various themes. These memories are activated when congruent situations are encountered. The emotional, psychological and physiological reactions are known as conditioned reflexes, memories are at their core. The schemas of the affective system are responsible for the various feeling states; happiness, sadness, anger, hate and anxiety are affective schemas. These schemas reinforce adaptive behaviours. Beck (1995) viewed these schemas as being analogous to sensory pain and pleasure in their effect on reinforcing behaviours.

Motivational and behavioural systems are described by Beck (1995) as being primal systems and include the fight or flight strategies, and other such basic biological requirements such as appetite and sexual expression. These systems are biologically endowed and whilst they can be consciously overridden they can occur automatically and independent of conscious intention.

The physiological system is closely aligned to schemas associated with threat, specifically the activities of the autonomic, motor and sensory nervous system. When activated they enhance the fight or flight systems, also the physiological symptoms can be interpreted; dependent upon individual schemas, as having potentially catastrophic outcomes (rapid heartbeat interpreted as a being a heart attack etc)

The conscious control system is the area of reflective, conscious, deliberate processes such as applying logic and future planning, this system is less reflective than the primal systems such as motivational and behavioural systems, and work at a conscious awareness level. It allows the individual to think at a meta-cognitive level, i.e. to think about thinking, and thus can be used to evaluate and override dysfunctional schema arising from other systems (Beck 1995)

Activation of the systems, particularly those at a more primal level depends upon the particular characteristics of the situation, and in particular an individual's conceptualisation and constructions of the situation and its circumstances. All the above systems work in an integrated and synchronised manner and are not necessarily discrete in their application. The increased activity of one of the more primal systems can create a skewing of information processing resulting in what Beck and Weishaar (1989) called a ‘cognitive shift’, whereby the introduction of systematic bias in to interpretation and inference sow the seeds for a variety of psychological disorders.

Becks’ CBT approach was designed to identify, empirically test and subsequently correct distorted conceptualisation and the dysfunctional beliefs or schemas that underpin those cognitions, by working at and on the conscious control system level.

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Psychological distress is triggered when there is impairment in cognitive processing.  Perception and interpretation become very selective and inflexible. The ability to rectify distorted thinking and perceptions through reality testing and refinement of overall conceptualisation is compromised.  Psychological distress is characterised by what Beck and Weishaar (1989) described as cognitive distortions, a shifting of information processing highly influenced by the primal system, resulting in systematic errors of reason. These cognitive distortions include arbitrary inference, where firm conclusions are drawn in the absence of evidence or even presence of contradictory evidence. Selective abstraction is similar in that the individual will selectively ...

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